{"id":379,"title":"CLAIM FORM COMMERCIAL CYBER LIABILITY INSURANCE","purpose":"claim","insurer":{"slug":"icici-lombard-general-insurance","name":"ICICI LOMBARD General Insurance Company Limited"},"source_pdf":"https://www.icicilombard.com/docs/default-source/default-document-library/commercial-cyber-liability-commercial.pdf","sha256":"351288f4b9d7054b9677774c214c18bd011075f9ab859b5e5deb1d9ee7fbaf2a","pages":3,"collected":"2026-10-20","instructions":{"about":"This form is for the insured policyholder to file a claim under the Commercial Cyber Liability Insurance policy.","notes":["Issuance of this form is not proof of admissibility of liability.","Please read the claim form fully before answering.","Complete and sign the form by the insured.","Answer all questions fully; use additional sheets if necessary.","Attach copies of relevant documentation.","All payments will be made only through electronic mode to the insured.","The company may condone delay in claim intimation/document submission on merit if delay is beyond insured's control.","Delay will not be condoned if claim would have been rejected even if reported in time."],"title":"CLAIM FORM COMMERCIAL CYBER LIABILITY INSURANCE","submit":{"to":"The Manager, Claims Department, ICICI Lombard General Insurance Company Limited","how":"post","address":"ICICI Lombard House, 414, Veer Savarkar Marg, Near Siddhi Vinayak Temple, Prabhadevi, Mumbai 400025"},"purpose":"claim","sections":[{"title":"Claimant Information","fields":[{"help":"","type":"text","label":"Name of the policyholder","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"State","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"City / Town / Village","options":[],"required":null,"pdf_field":""},{"help":"","type":"phone","label":"Phone No.","options":[],"required":null,"pdf_field":""},{"help":"","type":"email","label":"E-Mail Address","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Website","options":[],"required":null,"pdf_field":""},{"help":"","type":"text","label":"Fax Number","options":[],"required":null,"pdf_field":""},{"help":"","type":"number","label":"Pin Code","options":[],"required":null,"pdf_field":""},{"help":"Provide PAN card number","type":"text","label":"PAN Card Details","options":[],"required":null,"pdf_field":""},{"help":"If someone is representing the policyholder, provide their name","type":"text","label":"Represented by (if applicable)","options":[],"required":false,"pdf_field":""},{"help":"Enter the amount of loss claimed","type":"amount","label":"Loss Amount","options":[],"required":null,"pdf_field":""},{"help":"Describe the loss in brief; attach extra sheets if needed","type":"text","label":"Brief explanation of loss * (If additional space is needed for explanation attach as a separate document):","options":[],"required":true,"pdf_field":""},{"help":"Select Yes or No","type":"choice","label":"Are you or any of the proposed applicants/beneficial owner a PEP* or Family member/Close relatives/Associates of PEP*?","options":["Yes","No"],"required":null,"pdf_field":""},{"help":"Provide details if answered Yes above","type":"text","label":"If yes, please give details (Nature of relationship and position held by PEP):","options":[],"required":false,"pdf_field":""}],"filled_by":"insured"},{"title":"Details of Bank Account","fields":[{"help":"Name as per bank records","type":"text","label":"Name of Bank Account Holder","options":[],"required":null,"pdf_field":""},{"help":"Provide your bank account number","type":"text","label":"Bank Account No.","options":[],"required":null,"pdf_field":""},{"help":"Name of your bank","type":"text","label":"Name of Bank","options":[],"required":null,"pdf_field":""},{"help":"9 digit MICR code of your bank branch","type":"number","label":"MICR Code (9 digit)","options":[],"required":null,"pdf_field":""},{"help":"Tick if this is a savings account","type":"checkbox","label":"Saving Account","options":["Saving"],"required":null,"pdf_field":""},{"help":"Name of your bank branch","type":"text","label":"Branch","options":[],"required":null,"pdf_field":""},{"help":"11 digit IFSC code of your bank branch","type":"text","label":"IFSC Code (11 digit)","options":[],"required":null,"pdf_field":""},{"help":"Mandatory as per IRDAI for electronic payment","type":"checkbox","label":"I wish any payment due on the claims will be directly credited to my aforesaid Bank Account.*","options":[],"required":true,"pdf_field":""}],"filled_by":"insured"}],"deadlines":[],"applies_to":"Commercial Cyber Liability Insurance claims","attachments":["Latest salary slip verified by the entity issuing such slip (for lost wages claim)","Latest tax returns (for self-employed lost wages claim)","Proof of reporting to bank or credit organization (for unauthorized transaction loss)","Proof that the bank or credit organization is not indemnifying such loss","Complaint letter acknowledged by Police","Copy of Bank Statement","KYC documents if claim settlement amount is above INR 11 lakh","Additional sheets if explanation of loss requires more space"],"declarations":["The statements/information given in this claim form are true, correct and complete.","All persons having an interest in the property are disclosed and no similar claim has been made with any other insurer.","No material information relevant to the claim has been withheld or not disclosed.","If any false or fraudulent information is given, the policy shall be void and no claim rights will exist.","Receipt of this claim form or documents does not mean acceptance of the claim; the company may require further information.","The above statements are true and complete without reservation.","Consent is given to the company to verify identity/address proof through Central KYC Registry, UIDAI or other modes for KYC."],"dropped_labels":1},"pdf_fields":null,"fillable_pdf":false,"send_to":[],"how_to_use":"Ask the user for each field in order, in plain words; never invent an answer. Labels are as printed. If fillable_pdf is true, pdf_fields gives the PDF's own field names so the file can be filled directly. The printed form decides if anything differs.","url":"https://indiainsurances.com/forms/icici-lombard-general-insurance/379-claim-form-commercial-cyber-liability-insurance"}